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~~~ ~ <br />N - ~ ~ ~ ~ 7C ~^, A a <br />~ ~ ~ ~ ~ ~ ~ ~~ ~~ ~ ~ ~ ~ a <br />N I~t~ ~ ~ o t~ f ti.) ~ -r~ F-a (~ <br />~ ~~ 0.. ~j ~ ~, GJ ~n ,~ C7 Z <br />~I~I~ (R ~ 7"' Op <br />~Il~ww ~ -_....~r <br />C7!] ~ s Z <br />o <br />:. i;,~~ <br />W. "~ ~ <br />W1 <br />+ ~~~ <br />~~ ~ <br />~~ <br />~s~. <br />kL ••. ro <br />' M <br />+ r <br />i~ <br />C ~ <br />~ ~~ <br />za <br />r <br />~j• ~pV <br />• Ni 1~1 <br />. .., r- <br />~ ~ <br />r I".• <br />a- Ceih :' <br />~x <br />ft RI <br />- pw~ <br />3 ~^+ <br />~~ . <br />r <br />WHEN THIS COPYCARRE:S THE RAISED SEAL OF THE NEBRASKA HEAL7~IIND HUARVICES . <br />SYSTEM, fl' CERTIFlES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RF~[x ON FJC~"~T_ /l <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIES,~~ _ ~ <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS ~ - - 'f <br />DATE OF ISSUANCE _ ~ _~~ -- <br />2oioo2ss4 ~--.~.. w <br />JAN 7 ZQ02 ASSNS ~ RE°~ ~_ <br />LINCOLN, NEBRASKA HEALTH AND H17~4N'rEEL1[ICE ~ ~N~' <br />STATE OF NEBItASICA- D&PARTII~N'C OF HEALTH AND HUMAN SER33_CE9F`d$~A~~_ T <br />VITAL STATISTICS - -_ =~.•w ~~ ~ Q, <br />CERTIFICATE OF DEATH ~ -_ <br /> I. bECEDEN7-NAME FIRST MIbbLE LAST 2. SEX 3 DATE OF DEATH !Hoorn. bay. Pearl <br /> Clayton Corley Hessen, Jr. Male December 29, 2001 <br /> 4. CITY ANO SPATE pF BIRTH 111 not in US.A.. name country/ 5a. AGE ~ Last Blnhday UNDER f YEAR UNDER t DAV 6. PATE OF 81RTH IMornlr. Day. Year) <br /> <br />Beatrice, .Nebraska IYrs.l <br />55 56. MOS. I DAYS <br />' Sc. HOURS ~ MINS. <br />' <br />Jul 29, 1946 <br /> z SOCIAL SECURYIY NUMBER _ <br />Ba. PLACE OF DEATH __._._ <br /> <br />• 506-58-3702 fiDSPITAL: ^X InpaNenl OTHER. ^ Nursing Hpme <br />... <br /> 8D. FACILITY -Name /!l npl rn5lifUlpn, give 97reei and num6erJ ^ ER Outpatient ^ Residence <br /> St. Francis Memorial Health Centex ^ bnA ^ OIh9r /$Pecdyl.~ <br />_ - <br /> &, CITY. TOWN OR LOCATION OF DEAThI 8d. INSIDE CITY LIMITS ee. COUNTY qF bEA7H <br /> .... <br />Grand Island _ ~... -y_ <br />_ _ <br />tea Nn - _. <br /> <br />Hall <br /> -STATE 9b. COUNTY 9c. CIYV, TOWN OR LOCATION 9d. STREET ANb NUMBER /Including Prp Code) 9e INSIDE CITY LIMITS <br /> Nebraska Hall Grand Island 2512 W. Phoenix 68803 Yes ® Np ^ <br /> t0. RACE - Is.g.. white 81ack American Indian. 11. ANCESTRY le.g.. Italian. Mexican, German, 91c1 12. ®MARRIEp ~ WIDOwEb 13 NAME OF SPOUSE /n wile. yrve maiden name/ <br /> et°.I lspa°irl White IspBL1~l German NEVER - Dlvnac:Eb Jean E <br />Burns <br /> MARRI . <br /> <br /> <br />l as USUAL OCCUPATION /Grve kindW work done eurirrg most <br /> <br />t4b. KIND OF BUSINESS INDUSTRY _ <br />__ <br />t5 EDUCATION ISpecily only h~gnest gratle campletedl -..- <br /> nl wnrkrnq lire. even rr rpMpol Elementary or Secondary 10-12) College I t 4 or 5 ~ i <br /> ~. Owner <br />~ Colle Et 12 4 <br /> 16. FATHER ~ NAME FIRST MIDpLE <br />LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME <br /> Clayton Corley Hessen, 5r. <br />~ Norma Del <br />abar <br /> <br />18 WAS DECEASED <br />EVER IN U.S. ARMED FORCES? __ <br />__ <br />f 9a. INFORMANT -NAME ~'T ~~'w <br /> IYes. no. pr unk.l III yes. give war and dates of services! <br /> no Jean E. Hessen <br /> t96 INFORMANT MAILING AppRESS ISTREET OR R.F.p. NO.. CITY OR TOWN. STATE. ZIPI <br /> 2512 West Phoenix, Grand .Island, Nebraska 68$03 <br /> <br />20 EMBALMER IG U RLICENS N <br />~® i --.. ._~ <br />21 a. METHOD OF p16POSITiON 2rb DATE 2tc CEMETERY OR CHEMAIURV NAME <br /> (/(- _~ Gc. ~/Z27 x^BUr,at ^R9movai Jai nuary 2, 200 Grand Island City Cemeter~ <br /> 2a FUNERAL HOME ~ NAME M <br /> 2ttl CE <br />ETERY OH c:HEMA roRV LOCA7IUN GIV oR TOWN STATE <br /> <br />Apfel-Butler-Geddes I <br />^cr9mauvn ^p°na°°^ i Grand Island, Nebraska <br /> 22h FUNERAL HOME ADDRESS ISTREET OR R.F.b. NO.. CITY OR TOWN. STATE, ZIPI <br /> 1123 West Second Street, Grand Tsland, Nebraska 68801 <br /> ___ <br />23. IMMEp TE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR gal Ihl, AND Icll i Interval da(WBe <br />n <br />o <br />nset anA death <br /> PAR <br />i <br /> ' <br />\ <br />, <br />~~C~ <br />. ~~ C ~~ ~ <br />~~ ~ <br /> ~ <br />l <br />OR AS A CONSE ENCE OF <br />bUE <br />~...,. <br />...' ...................... .- _.-_....~.- I Iraerval bean ansel a <br />nd dealn <br />_.. <br /> <br /> <br />r ~ ^ ~~~ I <br />161 ~ rt1 ~ CR.. T ~ 11 ( I <br /> <br />~ <br /> pit1E TO.OR AS A CONSEQUENCE OF: <br />I Int bervevn asel and deaN <br />__ v r- <br />_..__. _ <br /> Ic) I <br /> PART OTHER SIGNIFICANT CDNpIT10NS -Conditions cOmrlbuting to the death but not related PART III IF FEMALE, WAS THERE A 24. AUTOPSY 25. WAS CASE REFERRED TO MEpICAL <br /> <br />N PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER <br /> IAgos 10-54) Vas N° Yes Nv Ves NO <br /> 26a. .DATE OF INJURY /Mp., bay, Yc/ 26c. HDUR OF INJURY 26d. DESCRIBE HOw INJURY OCCURREp <br /> Accident ~ Undetermined <br /> M <br /> Suicide ~ Pending 289. INJURY AT WDRK 261 PLACE QF INJURY - Al nom ,farm. street, tacrory <br />p rte lwriding, Bic. lSpeciyf 26g. LOCATION STREET OR R.F,D. NO. CITY OR TOwN STATE <br /> ^ <br />Ft9nipide Investigation ^ ^ <br />Yes No <br /> 27e. DATE OF DEATH /Mp.. Pay. Yrl 28a. DATE SIGNED /Mp.. bay. Yrl 286 TIME OF pEATH <br /> „~ Aecember 29 2001 sew M <br /> 276. DATE SIGNEp /MO.. pay Yci 27c. TIME OF pEATH ~ ~ k <br />J 28c. PRONpUNCEO DEAD lM°.. Oay. Ycl __ <br />YBO. PRONOUNCED OEAp /Hour! <br /> $g~ ec mb r 31 00 194'.3-` M ~ <br />~~ ~ <br />g <br />~ _.- M <br /> ,~ 27d T° the best of m Bath oC°urretl a time, dale antl place and tllre Iq Ina ~ 28e. On the basis of ezamrnanpn and-vr investigation, in my oprnrpn death occurred at <br /> causplsl stated. Q ~ the nme. date and pace and due to [he caaselsl stated. <br /> Si nawre and TiNel ~ Si nature and Title) ~ <br /> 29. dD TOIIACCO USE CONTRIBUTE TO TH EATH? 30.a HAS ORGAN pR TISSUE pONA710N SEEN CONSIDERED? 30.b wA5 CONSENT GRANTED? <br /> <br />YES ~ NO VNKNOWN <br />^ VES ~ NO (~~ <br />^ VES I ~(,~NO <br />`Y"° <br /> 3t NAME AND ADDRESS OF CERTIFIER IPHVSICIAN, CORONERS PHYSICIAN DR COVNTV ATTORNEVI /Typo ar Print) ~~- ~ <br /> Dr. Ran D. Crouch 800 Al ha Grand Island Ne <br /> 32a. REGISTRAR <br />-----.~~Ga ~,~,b„ 32G. bgTE FILED 8Y REGISTRAR /Mp., bay Yr./ <br />.IAiV d. ~M7 <br /> <br /> <br /> <br />